Provider Demographics
NPI:1346976990
Name:MEDNIS, NICOLE MARIE (LSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:MEDNIS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC HIGHLANDS
Mailing Address - State:NJ
Mailing Address - Zip Code:07716-1554
Mailing Address - Country:US
Mailing Address - Phone:848-254-0702
Mailing Address - Fax:
Practice Address - Street 1:135 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC HIGHLANDS
Practice Address - State:NJ
Practice Address - Zip Code:07716-1554
Practice Address - Country:US
Practice Address - Phone:848-254-0702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL066812001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical